What happened
On October 28, 2004, a Beechcraft F33A, registration PT-OFP, was performing a local flight at the Presidente Venceslau Aerodrome in Brazil. The pilot's original intention was to perform a ground engine run-up for maintenance purposes. However, the pilot decided to proceed with a full takeoff.
During the initial takeoff attempt, the pilot noticed the aircraft door was open and aborted the run. After taxiing to the opposite end of the runway to secure the door, the pilot attempted a second takeoff. During this departure, a loud noise was heard as the door became open again, causing papers to be sucked out of the cabin. This created significant stress and distraction for the pilot.
Following the takeoff, the pilot maintained the landing gear in the extended position and entered the traffic pattern to land quickly. During the final approach, the pilot experienced a momentary loss of consciousness, causing the aircraft to collide with the ground at the last contour before the runway threshold. The aircraft sustained severe damage, while the pilot sustained minor injuries.
The investigation
CENIPA's investigation revealed several critical regulatory and medical discrepancies. The pilot was operating with an expired medical certificate and an expired type rating for the specific aircraft model. Furthermore, the aircraft's airworthiness certificate (CA) was expired, and its maintenance logs were not up to date.
The investigation focused on the pilot's physiological state, noting that the pilot had been fasting for approximately eight hours due to a delay. The pilot was also using oral hypoglycemic medication with a long half-life, which, combined with the stress of the open door and lack of food, likely induced a hypoglycemic event leading to the loss of consciousness.
Findings
- Hypoglycemia: The loss of consciousness was likely caused by inadequate nutrition combined with the use of long-acting hypoglycemic medication and acute stress.
- Pilot Attitude: The pilot demonstrated a disregard for safety regulations and flight discipline, choosing to fly without authorization, without proper type training, and with expired documentation.
- Operational Errors: The pilot failed to properly secure the aircraft door, leading to the aerodynamic disturbance and subsequent stress during the flight.